A call for parity: 'There’s no physical health without mental health'

Three weeks after being appointed health secretary in Humza Yousaf’s government, Michael Matheson was in High Bonnybridge to visit community interest company Pause and Breathe. The wellbeing organisation, founded by former social worker Susie Hooper and her husband Phil Blackburn — a martial arts teacher — had been successful in winning £10,000 of funding from the government’s Communities Mental Health and Wellbeing Fund and Matheson used the trip to highlight what the fund does.

“This investment reflects the importance we place on promoting good mental health and early intervention for those facing mental health challenges, ensuring that people can access a range of different types of help to match their needs,” he said during the visit. “The fund will continue to support a range of valuable community mental health and wellbeing projects, reflecting one of the priorities set out by the first minister.”

Yousaf’s statement on his priorities for government, made in the wake of the Easter recess, was overshadowed by the arrest and subsequent release of now-former SNP treasurer Colin Beattie, but within it he said the government was committed to “improving mental health and welfare support”. The communities fund, which Matheson said had been boosted by £15m, is designed to help do that by providing a total of £51m across 3,300 grants over a three-year period. 

The sum, which equates to just £17m a year, is a drop in the ocean at a time when anxiety levels have soared in the wake of the coronavirus pandemic, suicide rates among disadvantaged males remain stubbornly high and when Public Health Scotland has highlighted the “important public health challenge” that poor mental health presents. Yet for Pause and Breathe the £10,000 will be transformational. Hooper says the organisation funds itself by offering a range of wellbeing sessions to paying customers, but with the grant it will be able to reach a wider client base by providing some sessions for free.

“Even the very simple thing of coming to a session gets you out of the house and mixing with other people, which is hugely beneficial to mental health,” she says. “People start to form connections and they see there are other people who feel the way they feel so they feel less alone. That’s before they take on board anything that’s offered in the session.”

The purpose of the government fund is to ensure that kind of community-based support is replicated across the country, but there are many other initiatives that take a similar approach. The century-old charity the Scottish Association for Mental Health, for example, runs projects including one at Hibernian and Heart of Midlothian football clubs that uses football to bring men together to talk through issues with their mental health.

Similarly, the Scottish Mental Health Arts Festival, which was established by the Mental Health Foundation 17 years ago, supports events in towns and villages across the country, celebrating the artistic achievements of people who have experienced mental health issues and using the arts as a way of highlighting how important it is for everyone to be mindful of their own mental health and wellbeing. It is, says festival officer Rob Dickie, “a grassroots, community-led festival” that each reaches “tens of thousands of people across hundreds of events” and “challenges stigma, engages people in mental health issues and connects communities”.

The wellbeing side is getting a lot of attention, and rightly so, but no matter how good wellbeing is you are only going to prevent a certain amount of mental illness

But there is a big difference between mental health and wellbeing on the one hand and mental ill health on the other and, according to Dr Jane Morris, vice-chair of the Royal College of Psychiatrists in Scotland, putting so much focus on the former — and promoting the idea that good mental health over here negates poor mental health over there — risks undermining how pressing it is to deal with the latter. Charities, community organisations and voluntary groups across the country are doing vital work around mental health and wellbeing — work that ultimately takes some of the pressure off the NHS — but Morris stresses that even in that scenario mental illness continues to exist and for that a medical solution will often be required.

“Our fear is that there doesn’t seem to be a department [in the Scottish Government] that’s considering mental illness,” Morris says. “The wellbeing side is getting a lot of attention, and rightly so, but no matter how good wellbeing is you are only going to prevent a certain amount of mental illness. At the moment there’s such a lack of mental health that we have to accept that we have a lot of mental illness — mental illness that is responsive to treatment. I’m not talking about will I or won’t I prescribe an anti-depressant, I’m not talking about the kind of illness where some people might say ‘don’t medicate that’. I don’t want to medicate social issues or deprivation, but there’s always going to be a certain amount of mental illness in the same way there will always be some heart problems, and so on. We’ve got new ministers in post, but I don’t anywhere see mental illness as being listed [as a specific portfolio responsibility].”

When it announced its 10-year mental health strategy in 2017, the Scottish Government said the aim was to “achieve parity between mental and physical health”, something that was reiterated by Clare Haughey, the then minister for mental health, when she announced a review of the Mental Health Act in 2019. Since then there has been a global pandemic and a significant heightening of cost-of-living concerns – two things that have not only worsened mental ill health but worsened inequalities in how people experience mental health, too.

Yet, more recently, the government has appeared unwilling to match its rhetoric with resource, with John Swinney – who was acting as finance secretary at the time the last budget was passed – initially announcing that mental health funding would be cut to help pay for public sector pay deals before settling on a budget freeze for the 2023-24 financial year. The overall health and social care budget increased by over £1bn, but spending on mental health services remained unchanged at £290.2m, with the government justifying the move by noting that “mental health spending has almost doubled in cash terms since 2007”.

Difficult decisions are being made across Holyrood and it’s easy from the outside to be unhappy, but why when health spending was increased was mental health not part of that?

It is, says Lee Knifton, co-director of the Centre for Health Policy at the University of Strathclyde and Scotland director the Mental Health Foundation, a poor message for Holyrood to send.

“Difficult decisions are being made across Holyrood and it’s easy from the outside to be unhappy, but why when health spending was increased was mental health not part of that?,” he says. “If the rationale is that there was a big increase previously that doesn’t add up because the increase was to create parity. This is a slip back and the concern is that we’re now in a situation that’s really, really difficult. We’re seeing real increases in poor mental health and we will see a big demand on services and bigger pressure on budgets.

“We know that poor mental health and mental ill health are on the increase. There had been increasing signs before the pandemic […..] but what we have seen is that the pandemic has been enormously important in this, as has the worsening of poverty. It was already there in Scotland. If you look at Glasgow and issues around addiction, suicide and poor physical health, mental health is the cause of the cause. Mental health has driven that for two generations at least.”

When the budget was announced, the Royal College of Psychiatrists issued a statement that made clear its dismay at the refusal to increase investment in the sector. Noting that Swinney had announced help for families and services during the cost-of-living crisis but had made no mention of mental health care, the organisation’s policy lead Dr Pavan Srireddy said that “what we have here is a mental health catastrophe in the making”.

“People are really struggling with the cost-of-living crisis, which is having an enormous toll on their mental health,” he said. “It’s quite astonishing that during this time budgets for mental health care are being frozen. While provisions were put in place during Covid-19, in stark contrast, budgets have been frozen for mental health services in response to the current cost-of-living crisis. We wanted the Scottish Government to guarantee that 10 per cent of health spend is given to mental health and it receives its fair share of funding, but, sadly, what we’ve seen in this budget is a cut in real terms. We need firm assurances we will see this promised uplift.”

Morris says the “only revision we could possibly make to that strongly worded statement now would be to make it even more strongly worded”. “We do understand that there has been immense hardship in every sector and for everybody, but we feel that the commitment for parity between physical and mental health has not been maintained,” she says, adding that that makes no sense because “there’s no physical health without mental health — the two are completely intertwined”.

Last year the government consulted on how it could refresh the 2017-2027 strategy at the half-way point, the results of which were published at the beginning of this year. It received just under 500 responses, with those taking part highlighting the need for a stronger focus on prevention and early intervention, the importance of tackling deep-seated inequalities and the urgency around addressing workforce issues such as recruitment and retention. Placing mental health and wellbeing on an equal footing with physical health was also listed as a key priority.

The government is using the consultation to “inform” a new mental health and wellbeing strategy that is due to be published this spring, though it is notable that in the government’s A Fresh Start priorities document mental health gets just one bullet point, with Matheson committing to improve mental health and wellbeing support, reduce waiting times for Child & Adolescent Mental Health Services, and oversee the “ongoing implementation of our suicide prevention strategy”. It is against that backdrop that Knifton says the new mental health plan “needs to be radical”.

“Mental health in Scotland is particularly bad and it’s worsening,” he says. “It’s fixable, but we shouldn’t look for one solution or one soundbite. For me, there are good and bad things here. One of the very good things is that at points the political parties have been more respectful of each other in terms of mental health. That’s better than using soundbite criticisms that stop [the government] providing actual help. I hope that will hold.

“In broad terms I would like a mental health strategy that commits to prevention, spells out what that means to government and has significant resources behind it. I’d like to see a commitment to reducing inequalities in mental health because poverty is one of the strongest influences. Every government department and council [needs to be involved]. There’s a gap if we’re not careful in Scotland in terms of what we’re doing with services. Often the government sets out a big strategic vision then says councils are responsible — it all needs to tie together.”

The main reason people can’t access mental health treatment is that our workforce is haemorrhaging, there are too few psychiatrists and so waiting lists are too long

For Morris, the promise to put mental health on an equal footing with physical health is key to everything else. Without that, none of the other priorities will be met because those working in the sector will continue to firefight crises rather than being able to prevent them occurring in the first place.

“The main reason people can’t access mental health treatment is that our workforce is haemorrhaging, there are too few psychiatrists and so waiting lists are too long,” she says. “That means we have to prioritise people in acute crisis and that means that early intervention work can’t get done and things pile up. 

“As an individual I would say to the government, see us [psychiatry] as a medical specialty and give us all the same respect and investment that you would your very best cancer doctors. Speaking on behalf of the Royal College of Psychiatrists I would have to try to reframe that but I would say make sure mental illness is treated with the same parity as physical illness and be upfront in acknowledging mental illness as much as mental wellbeing. The vast majority of us will meet the criteria for at least one diagnosable and treatable mental illness before we reach mid-life. We’re wasting the wonderful potential of the Scottish people if we don’t make sure those illnesses are treated promptly and compassionately.”